Providence St Vincent Portland 01-07-09

CLINICAL SITE INFORMATION FORM (CSIF) developed by APTA Department of Physical Therapy Education Why have a consistent Clinical Site Information Form? The primary purpose of this form is for Physical Therapist (PT) and Physical Therapist Assistant (PTA) academic programs to collect information from clinical education sites This information will facilitate clinical site selection, student placements, assessment of learning experiences and clinical practice opportunities available to students; and provide assistance with completion of documentation for accreditation in clinical education How is the form designed? The form is divided into two sections, Information for Academic Programs - Part I (pages 3-14) and Information for Students - Part II (pages 15-17), to allow ease in retrieval of information for academic programs and for students, especially if the academic program is using a database to manage the information Duplication of information being requested is kept to a minimum except when separation of Part I and Part II of the form would omit critical information needed by both students and the academic program The form is also designed using a check-off format wherever possible to reduce the amount of time required for completion This instrument can be retrieved from APTA's website at www.apta.org Simply select the link titled “PT Education”, then the link titled “Clinical Education” and choose “Clinical Site Information Form” Although using a computer to complete the form is not mandatory, it is highly recommended to facilitate legible updates with minimal time investment from your facility Additionally, the information provided will be more legible to students, academic programs, and the APTA’s Department of Physical Therapy Education The form includes several features designed to streamline navigation, including a hyperlinked index on page 18 (Please notes that several of the hyperlinks contained in the document require your computer to have an open internet connection and a web browser) If you prefer to complete the form manually, you may download the CSIF from APTA's website (see above) If you not have access to a computer for this purpose, hard copies of the CSIF are available from the APTA Department of Physical Therapy Education, as well as from all PT and PTA academic programs through their Academic Coordinator of Clinical Education (ACCE) What should I once the form has been completed? We encourage you to invest the time to complete the form thoroughly and accurately Once the form has been completed, the clinical education site may e-mail the instrument to each academic program with which it affiliates, minimizing administrative time and associated costs Please remember to make a copy of this form and retain for your records! To assist in maintaining accurate and relevant information about your physical therapy service for academic programs and students, we encourage you to update this form on an annual basis In addition, to develop and maintain an accurate and comprehensive national database of clinical education sites, we request that a copy of the completed form be e-mailed to the Department of Physical Therapy Education at csif@apta.org or mail to: Department of Physical Therapy Education 1111 North Fairfax Street Alexandria, Virginia 22314 DIRECTIONS FOR COMPLETION: If using a computer to complete this form: When completing this form, after opening the original form, and before entering your facility’s information, save the form The title should be your zip code, your site’s name, and the date (eg, 90210BevHillsRehab10-26-99 Please note that the date must be set apart with dashes; if slashes are used, the computer will unsuccessfully search for a directory and return an error message) Saving the document will preserve the original copy on the disk or hard drive, allowing for you to easily update your information When completing, use the tab key or arrow keys to move to the desired blank space (the form is comprised of a series of tables to enable use of the tab key for easier data entry) Enter relevant information only in blank spaces as appropriate to your clinical site What should I if my physical therapy service is associated with multiple satellite sites that also provide clinical learning experiences? If your physical therapy service is associated with multiple satellite sites (for example, corporate hospital mergers) that offer clinical learning experiences, such as an acute care hospital that also provides clinical rotations at associated sports medicine and long-term care facilities, you will need to complete pages and On page 3, provide the primary clinical site for the clinical experience On page 4, indicate other clinical sites or satellites associated with the primary clinical site Please note that if the individual facility information varies with each satellite site that offers a clinical experience, it will be necessary to duplicate a blank CSIF and complete the form for each satellite site that offers different clinical learning experiences What should I if specific items are not applicable to my clinical site or I need to further clarify a response? If specific items on the form not apply to your clinical education site at the time you are completing the form, please leave the item blank Opportunities to provide comments have been made available throughout the form CLINICAL SITE INFORMATION FORM I Information About the Clinical Site Date 11/27/08 Person Completing Questionnaire Maureen Gonzales, PT/OP CCCE for Out Patient Services Scholls Physical Therpay 12442 SW Scholls Ferry rd Tigard Or 97224 Victoria Reichman, OTR/L CCCE for Outpatient Peds Maureen Cronin PT CCCE for In Patient Services 9155 SW Barnes Rd 9135 SW Barnes Rd Suite 361 Portland, OR 97225 Portland, OR 97225 Name of Clinical Center Providence St Vincent Medical Center Street Address 9135 SW Barnes Rd., Suite 361 City Portland Facility Phone 503-216-1234 Ext PT Department Phone 503-216-2610 Ext PT Department Fax 503-216-4071 State OR Zip 97225 PT Department E-mail Web Address Director of Physical Therapy Cathy Zarosinski, PT Director of Physical Therapy E-mail cathy.zarosinski@providence.org Center Coordinator of Clinical Education (CCCE) / Contact Person IP : Maureen Cronin PT OP: Maureen Gonzales, PT Peds: Victoria Reichman OTR Maureen Cronin: 503-216-0298 Maureen Gonzales: 503-216-9280 Victoria Reichman: 503-216-0441 Maureen C: maureen.cronin@providence.org Maureen G: maureen.gonzales@providence.org Victoria: Victoria.reichman@providence.org CCCE / Contact Person Phone CCCE / Contact Person E-mail Complete the following table(s) if there are multiple sites that are part of the same health care system or practice Copy this table before entering information if you need more space Name of Clinical Site Raleigh Hills Physical Therapy Street Address 8375 SW Beaverton Hillsdale Hwy City Portland Facility Phone 503-292-5324 Ext PT Department Phone 503-292-5324 Ext Fax Number 503-292-5577 Director of Physical Therapy Center Coordinator of Clinical Education/contact (CCCE) Cathy Zarosinski E-mail cathy.zarosinsky@providence.org Maureen Gonzales E-mail maureen.gonzales@providence.org Name of Clinical Site Mercantile Medical Plaza Street Address 4035 SW Mercantile Drive City Lake Oswego Facility Phone 503-216-2788 Ext PT Department Phone 503-216-2788 Ext Fax Number 503-635-4837 Director of Physical Therapy Center Coordinator of Clinical Education/contact (CCCE) Cathy Zarosinsky, PT E-mail cathy.zarosinsky@providence.org Maureen Gonzales, PT E-mail maureen.gonzales@providence.org Name of Clinical Site Tanasbourne Medical Plaza Street Address 1885 NW 185 th Ave City Aloha Facility Phone 503-216-9760 Ext PT Department Phone 503-216-9764 Ext Fax Number 503-216-9764 Director of Physical Therapy Center Coordinator of Clinical Education/contact (CCCE) Cathy Zarosinsky, PT E-mail cathy.zarosinski@providence.org Maureen Gonzales, PT E-mail maureen.gonzales@providence.org State OR Zip 97225 Facility E-mail State OR Zip 97034 Facility E-mail State OR Zip 97006 Facility E-mail Name of Clinical Site Providence Sports Therapy Street Address 9135 SW Barnes Rd su 361 City Portland Facility Phone 503-216-3125 Ext PT Department Phone 503-216-3125 Ext Fax Number 503-216-3140 Director of Physical Therapy Cathy Zarosinsky, PT E-mail cathy.zarosinsky@providence.org Center Coordinator of Clinical Education/contact (CCCE) Maureen Gonzales, PT E-mail maureen.gonzales@providence.org Name of Clinical Site Scholls Street Address 12442 SW Scholls Ferry rd su 202 City Tigard Facility Phone 503-216-9280 Ext PT Department Phone 503-216-9280 Ext Fax Number 503-216-9284 Director of Physical Therapy Center Coordinator of Clinical Education/contact (CCCE) Cathy Zarosinski E-mail cathy.zarosinski@ providence.org Maureen Gonzales E-mail maureen.gonzales@providence.org Name of Clinical Site Bridgeport Rehab Street Address 18040 SW Lower Boones Ferry Rd City Tigard Facility Phone 503-216-0680 Ext PT Department Phone SAA Ext Fax Number 503-216-0685 Director of Physical Therapy Center Coordinator of Clinical Education/contact (CCCE) Cathy Zarosinski, PT E-mail cathy.zarosinski@providence.org Maureen Gonzales, PT E-mail maureen.gonzales@providence.org State OR Zip 97225 Facility E-mail State OR Zip 97223 Facility E-mail State OR Zip 97224 Facility E-mail Name of Clinical Site Orenco Rehabilitation Street Address 5555 NE Elam Young Pkwy City Hillsboro OR Facility Phone Zip 97124 Ext PT Department Phone (503) 216-1690 Ext Fax Number (503) 216-1695 Director of Physical Therapy Center Coordinator of Clinical Education/contact (CCCE) Cathy Zarosinski, PT E-mail cathy.zarosinski@providence.org Maureen Gonzales, PT E-mail maureen.gonzales@providence.org Name of Clinical Site Vernonia Physical Therapy Street Address 510 Bridge Street City Vernonia Facility Phone 503-216-2004 Ext PT Department Phone 503-216-2004 Ext Fax Number 503-429-6900 Director of Physical Therapy Center Coordinator of Clinical Education/contact (CCCE) Cathy Zarosinski, PT E-mail cathy.zarosinski@providence.org Maureen Gonzales, PT E-mail maureen.gonzales@providence.org Name of Clinical Site Providence Neurodevelopmental Center for Children Street Address 9155 SW Barnes Rd City Portland Facility Phone 503-216-2339 Ext PT Department Phone 503-216-2339 Ext Fax Number 503-216-6813 Director of Physical Therapy Center Coordinator of Clinical Education/contact (CCCE) Scott Shroeder, SLP E-mail Scott.Schroeder@providence.org Victoria Reichman, OT E-mail Victoria.reichman@providence.org State OR Zip 97064 Facility E-mail State OR Zip 97225 Facility E-mail Clinical Site Accreditation/Ownership Yes No X Date of Last Accreditation/Certification Is your clinical site certified/ accredited? If no, go to #3 If yes, by whom? X X X 2003 JCAHO JCAHO Certified Stroke Center CARF 2006 2007 Government Agency (eg, CORF, PTIP, rehab agency, state, etc.) Other NCQA 1990 Rehab Agency 2000 Who or what type of entity owns your clinical site? PT owned X_ Hospital Owned General business / corporation Other (please specify) _ Place the number next to your clinical site’s primary classification noted in bold type Next, if appropriate, mark (X) up to four additional bold typed categories that describe other clinical centers associated with your primary classification Beneath each of the five possible bold typed categories, mark (X) the specific learning experiences/settings that best describe that facility Acute Care/Hospital Facility Functional Capacity Exam- FCE spinal cord injury university teaching hospital industrial rehab traumatic brain injury X Pediatric other (please specify) other X cardiopulmonary Federal/State/County Health X School/Preschool Program X Orthopedic Veteran’s Administration X school system X Other pediatric develop ctr preschool program X Ambulatory Care/Outpatient adult develop ctr early intervention X Geriatric other other X hospital satellite Home Health Care medicine for the arts agency Orthopedic contract service other pain center hospital based Other Pediatric other international clinical site X X Wellness/Prevention Program X on-site fitness center Podiatric Rehab/Subacute Rehab administration X sports PT inpatient research X Other outpatient other ECF/Nursing Home/SNF Ergonomics pediatric work hardening/conditioning geriatric adult 4a Which of these best characterizes your clinic’s location? Indicate with an ‘X’ rural suburban X urban If your clinical site provides inpatient care, what are the number of: 523 Acute beds ECF beds Long term beds 35 Psych beds Rehab beds Step down beds Subacute/transitional care unit 523 Other beds (please specify): Total Number of Beds II Information about the Provider of Physical Therapy Service at the Primary Center PT Service hours Days of the Week From: (a.m.) To: (p.m.) Monday 7:00am 7:00pm Tuesday 7:00am 7:00pm Wednesday 7:00am 7:00pm Thursday 7:00am 7:00pm Friday 7:00am 7:00pm Saturday 7:00am 5:30pm Sunday 7:00am 5:30pm Comments Sun services: IP and ER Only Sat : OP Providence Sport Therapy only Describe the staffing pattern for your facility: Standard hour day Varied schedules _X (Enter additional remarks in space below, including description of weekend physical therapy staffing pattern) Indicate the number of full-time and part-time budgeted and filled positions: Full-time budgeted PTs 29 / OP There are about 33 PTs in OP at the hospital and satellites There is not an accurate breakdown available as to full and part time Part-time budgeted 20 / OP IP PTAs status 11 IP IP 1/ OP, IP Aides/Techs 12/ OP, IP 2/ OP, IP Estimate an average number of patients per therapist treated per day by the provider of physical therapy INPATIENT OUTPATIENT 12 Individual PT 12-14 Individual PT 12 Individual PTA 12 Individual PTA 120 Total PT service per day 350 Total PT service per day III Available Learning Experiences 10 Please mark (X) the diagnosis related learning experiences available at your clinical site: X Amputations X Critical care/Intensive care X Neurologic conditions X Arthritis X Degenerative diseases X Athletic injuries X General medical conditions X Traumatic brain injury Burns X General surgery/Organ Transplant X Other neurologic conditions X Cardiac conditions X Hand/Upper extremity X Oncologic conditions X Cerebral vascular accident X Industrial injuries X Orthopedic/Musculoskeletal X Chronic pain/Pain X ICU (Intensive Care Unit) X Pulmonary conditions X Connective tissue diseases X Mental retardation X Wound Care X Congenital/Developmental Spinal cord injury Other (specify below) 11 Please mark (X) all special programs/activities/learning opportunities available to students during clinical experiences, or as part of an independent study X Administration X Industrial/Ergonomic PT X Prevention/Wellness X Aquatic therapy X Inservice training/Lectures X Pulmonary rehabilitation Back school X Neonatal care X Quality Assurance/CQI/TQM Nursing home/ECF/SNF X Radiology X Biomechanics lab X Cardiac rehabilitation/phase X On the field athletic injury X Research experience X Orthotic/Prosthetic fabrication X Screening/Prevention X Community/Re-entry activities Critical care/Intensive care X Pain management program X Sports physical therapy X Departmental administration X Pediatric-General (emphasis on): X Surgery (observation) Early intervention X Classroom consultation X Team meetings/Rounds Employee intervention X Developmental program X Women’s Health/OB-GYN X Employee wellness program X Mental retardation X Work Hardening/Conditioning X Group programs/Classes X Musculoskeletal X Wound care X Home health program X Neurological Other (specify below) X Lymphodema, Vestibular 12 Please mark (X) all Specialty Clinics available as student learning experiences Amputee clinic Neurology clinic Arthritis Orthopedic clinic Feeding clinic X Screening clinics X Developmental Pain clinic Scoliosis Hand clinic Preparticipation in sports Sports medicine clinic Hemophilia Clinic Prosthetic/Orthotic clinic Other (specify below) Industry Seating/Mobility clinic 13 Please mark (X) all health professionals at your clinical site with whom students might observe and/or interact X Administrators Health information technologists X Alternative Therapies X Nurses X Athletic trainers X Occupational therapists X Audiologists X Physicians (list specialties) X Dietitians Physician assistants X Enterostomal Therapist Podiatrists Exercise physiologists Prosthetists /Orthotists Psychologists X Respiratory therapists X Therapeutic recreation therapists Social workers Special education teachers X Vocational rehabilitation counselors Others (specify below) 14 List all PT and PTA education programs with which you currently affiliate AT Still University University of Iowa Chapman University University of Mary Idaho State University, PT University of Montana Belmont University University of North Dakota University of Puget Sound Marquette University University of the Pacific Mt Hood Community College University of Southern California Pacific University 15 What criteria you use to select clinical instructors? (mark (X) all that apply): X APTA Clinical Instructor Credentialing Career ladder opportunity X Demonstrated strength in clinical teaching Certification/Training course X Therapist initiative/volunteer X Clinical competence X Years of experience X Delegated in job description No criteria Other (please specify) 16 How are clinical instructors trained? (mark (X) all that apply) X 1:1 individual training (CCCE:CI) X Academic for-credit coursework X APTA Clinical Instructor Credentialing Clinical center in-services X X Continuing education by consortia No training X 10 Professional continuing education (eg, chapter, CEU course) Other (please specify) CONTINUING PROFESSIONAL PREPARATION RELATED DIRECTLY TO CLINICAL TEACHING RESPONSIBILITIES (for example, academic for credit courses [dates and titles], continuing education [courses and instructors], research, clinical practice/expertise, etc in the last five years): Dispelling the CI Myth: Students are Fun May 2, 2007 CLINICAL INSTRUCTOR INFORMATION Provide the following information on all PTs or PTAs employed at your clinical site who are CIs Name School from Which CI Graduated PT/PTA Year of Graduation No of Years of Clinical Practice No of Years of Clinical Teaching Credentialed CI Pacific University PT ‘99 10 2005 credentialed CI 3839 OR Dolores Niebergall Universtiy of Puget Sound PT ‘84 24 13 2620 OR Katie Carr Chapman PT 2000 2005 credentialed CI 4087 OR Karen Caliendo Mount Hood Community College Hunter College PTA ‘92 17 2005 credentialed CI 7659 OR PT ‘96 12 ATC certification 2002 4108 OR Specialist Certification Other L= Licensed, Number E= Eligible T= Temporary L/E/T Number State of Licensure Barb Nicholson Michele Shivak (Continued on next page) 18 CLINICAL INSTRUCTOR INFORMATION (continued) Name School from Which CI Graduated PT/P TA Year of Graduation No of Years of Clinical Practice No of Years of Clinical Teaching Credentialed CI Specialist Certification Other Gerrit Kockx Twenti Academy of Physiotherapy Joan Reed Pacific Universty PT L= Licensed, Number E= Eligible T= Temporary L/E/T Number State of Licensure 1986 23 17 2005 credentialed for CI 2117 OR 1986 23 20 1561 OR PT Deb Maier University of British Columbia PT 1980 28 25 2112 OR Patti Seely University of Pennsylvania PT 1976 33 32 2300 OR Arin Short Idaho State University PT 2001 4184 OR Barbie Carter University of Southern California PT 1985 24 17 1495 OR Jon Caulley University of Puget Sound PT 2000 4001 OR Tod Betters Pacific University PT 1999 10 2005 credentialed CI 3872 OR 19 Teresa Schmidt Pacific University College PT 1996 13 12 3276 OR Kim Campbell Northwestern University PT 1995 12 11 3669 OR Jeannie Williams New York University PT 1985 25 22 1959 OR Karen Kloppenburg California State University Northridge UCLA University of Connecticut PT 1981 28 26 1332 OR PT 1996 12 4209 OR Marie Ellingson College of St Scholastica PT 1980 27 16 1299 OR Susan Carrigg Duke University PT 1991 18 16 2200 OR M.J Strauhal Russel Sage College PT 1980 29 18 1429 OR Bob Isler University of Wisconsin PT 1991 18 16 2317 OR Kay Steffen University of North Dakota PT 1977 32 31 Credentialed CI 804 OR Nora Stern Boston University PT 1995 14 12 3189 OR Donna Hale-Jones 20 Kristine Samuelson Pacific University PT 1994 15 13 2815 OR Shellie Lyden Pacific University PT 1997 12 11 3424 OR Kelly Powers Marquette University PT 1990 19 16 2560 OR Maureen Gonzales University of Washington PT 1978 30 19 Credentialed CI 2005 1986 OR Donna Jackson CSULB PT 1977 32 31 2081 OR Jessica Shelton University of Florida PT 1996 12 10 1998 5019 OR Beth Gore Pacific University PT 1996 12 3295 OR George, Jennifer Chapman University PT 2000 4099 OR Adams, Betsy Ohio State University PT 1970 24 0571 OR Conedera, Jerry California State University at Long Beach PT 1972 37 0418 OR 21 Fujimori, Reid University of Colorado Health Sciences Center Ithaca PT 2004 5403 17173 8811 OR MA CO PT 1978 30 29 scheduled to take course in January 2008 0987 OR Hendrickson, Susan Pacific University PT 1997 11 3437 OR Irvine, Debra California State University at Long Beach PT 1996 12 11 Credentialed CI 2005 4556 OR McCorkle, Marcia University of Colorado PT 1970 17 0032 OR Collinson, Erin Pacific University DPT 2007 1.5 0 5416 OR Smithberger, Luke University of Indianapolis DPT 2008 0.5 Children’s Fitness Specialist 5678 OR Oberfield, Susan Marquette University PT 1987 21 20 Credentialed CI 2005 4162 OR Stump, Melissa Indiana University DPT 2008 months 0 5731 OR Grossman, Randy 22 Speer, Brad Pacific University PT 1999 3874 OR Cronin, Maureen QuinnipiacColl ege PT 1976 26 26 Credentialed CI 2006 0952 OR Woodward, Eric Pacific University PT 1984 21 11 1374 OR Garriott, Catherine Mount Hood Community College PTA 1984 24 18 7544 OR Heller, Shelley Mount Hood Community College PTA 1992 16 12 7666 OR Lee, Patrick Henry Ford Community College PTA 1999 Credentialed CI 2008 8118 OR Mattson, Sheri Mount Hood Community College PTA 1975 17 7078 OR Susan Perry LA Pierce College PTA 1983 25 24 2005 credentialed CI 7802 OR Jeanne Baldwin Pacific University PT 2002 Yes 4472 OR 23 Knudsen, Kati USC PT 1996 12 10 Pineda, Amy University of Missouri -Columbia PT 1999 Rosoff, Jennifer University of Vermont PT 1985 23 21 Wolfe, Stephanie Pacific University PT 2006 Schuster, Cressa Pacific University PT 2007 1.5 24 APTA board certified Pediatric Clinical Specialist Credentialed CI 3333 OR 4755 OR 1574 OR Pediatric Clinical Specialist, Certified Administrator Sensory Integration & Praxis Test, Certified Infant Massage Instructor Credentialed CI 5230 OR Credentialed CI 5455 OR 18 Indicate professional educational levels at which you accept PT and PTA students for clinical experiences (mark (X) all that apply) Physical Therapist Physical Therapist Assistant X First experience X First experience X Intermediate experiences X Intermediate experiences X Final experience X Final experience X Internship PT 19 Indicate the range of weeks you will accept students for any single full-time (36 hrs/wk) clinical experience From weeks To 16 weeks 20 Indicate the range of weeks you will accept students for any one part-time (< 36 hrs/wk) clinical experience weeks weeks 21 Average number of PT and PTA students affiliating per year 15-20 in OP in IP PT PTA From To week weeks week weeks PTA in OP in IP 22 What is the procedure for managing students with exceptional qualities that might affect clinical performance (eg, outstanding students, students with learning/performance deficits, learning disability, physically challenged, visually impaired)? No written procedure Each student “managed” according to their needs/abilities 23 Answer if the clinical center employs only one PT or PTA Explain what provisions are made for students if the clinical instructor is ill or away from the clinical site NA 25 Yes No X 24 Does your clinical site provide written clinical education objectives to students? If no, go to # 27 25 Do these objectives accommodate: the student’s objectives? students prepared at different levels within the academic curriculum? academic program's objectives for specific learning experiences? students with disabilities? 26 Are all professional staff members who provide physical therapy services acquainted with the clinical site's learning objectives? X X X X X 27 When the CCCE and/or CI discuss the clinical site's learning objectives with students? (mark (X) all that apply) X Beginning of the clinical experience X At mid-clinical experience Daily X At end of clinical experience X Weekly X Other 28 How you provide the student with an evaluation of his/her performance? (mark (X) all that apply) X Written and oral mid-evaluation X Ongoing feedback throughout the clinical X Written and oral summative final X As per student request in addition to formal and evaluation ongoing written & oral feedback X Student self-assessment throughout the clinical Yes No X 29 Do you require a specific student evaluation instrument other than that of the affiliating academic program? If yes, please specify: OPTIONAL: Please feel free to use the space provided below to share additional information about your clinical site (eg, strengths, special learning opportunities, clinical supervision, organizational structure, clinical philosophies of treatment, pacing expectations of students [early, final]) Information for Students - Part II I Information About the Clinical Site 26 Yes No X Do students need to contact the clinical site for specific work hours related to the clinical experience? Do students receive the same official holidays as staff? X X Does your clinical site require a student interview? Indicate the time the student should report to the clinical site on the first day of the experience: Per student’s phone conversation with CI or as directed by CCCE Medical Information Yes No X Comments Is a Mantoux TB test required? a) one step _ b) two step _ 5a If yes, within what time frame? X X Is a Rubella Titer Test or immunization required? Are any other health tests/immunizations required prior to the clinical experience? a) If yes, please specify: varicella X How current are student physical exam records required to be? Are any other health tests or immunizations required onsite? a) If yes, please specify: X 10 Is the student required to provide proof of OSHA training? X 11 Is the student required to attest to an understanding of the benefits and risks of Hepatitis-B immunization? 12 Is the student required to have proof of health insurance? X Not Required a) Can proof be on file with the academic program or health center? 13 Is emergency health care available for students? X X a) Is the student responsible for emergency health care costs? 14 Is other non-emergency medical care available to students? X X X 15 Is the student required to be CPR certified? (Please note if a specific course is required) a) Can the student receive CPR certification while on-site? X 16 Is the student required to be certified in First Aid? X Yes X a) Can the student receive First Aid certification on-site? No Comments 17 Is a criminal background check required (eg, Criminal Offender Record Information)? 27 Must be on Providence Background Check form and signed off by the ACCCE X a) Is the student responsible for this cost? X 18 Is the student required to submit to a drug test? X 19 Is medical testing available on-site for students? Or the school may pick up the cost Prior to start of clinical Housing Yes No Comments X 20 Is housing provided for male students? X for female students? (If no, go to #26) $ 21 What is the average cost of housing? 22 If housing is not provided for either gender: a) Is there a contact person for information on housing in the no area of the clinic? (Please list contact person and phone #) b) Is there a list available concerning housing in the area of the clinic? If yes, please attach to the end of this form 23 Description of the type of housing provided: 24 How far is the housing from the facility? 25 Person to contact to obtain/confirm housing: Name: Address: City: State: Zip: Transportation Yes No X 26 Will a student need a car to complete the clinical experience? X $ 27 Is parking available at the clinical center? a) What is the cost? X 28 Is public transportation available? 29 How close is the nearest bus stop (in miles) to your site? a) train station? b) subway station? 30 Briefly describe the area, population density, and any safety issues regarding where the clinical center is located 31 Please enclose printed directions and/or a map to your facility Travel directions can be obtained from several travel directories on the internet (eg, Delorme , Microsoft , Yahoo) May need one for a pediatric clinical On site for hospital, varies for OP clinical sites 25 mi Suburban Meals Yes X No Comments 32 Are meals available for students on-site? (If no, go to #33) 28 X Breakfast (if yes, indicate approximate cost) $ X Lunch (if yes, indicate approximate cost) $ X Dinner (if yes, indicate approximate cost) $ X a) Are facilities available for the storage and preparation of food? Meals available at some sites Stipend/Scholarship Yes No X Comments 33 Is a stipend/salary provided for students? If no, go to #36 $ a) How much is the stipend/salary? ($ / week) 34 Is this stipend/salary in lieu of meals or housing? 35 What is the minimum length of time the student needs to be on the clinical experience to be eligible for a stipend/salary? Special Information Yes No X Comments 36 Is there a student dress code? If no, go to # 37 a) Specify dress code for men: See attached b) Specify dress code for women: See Attached X 37 Do you require a case study or inservice from all students? X 38 Does your site have a written policy for missed days due to illness, emergency situations, other? Clinicals of weeks or more for in-pt., case studies or inservice for PTA students Other Student Information Yes X X X X X X No 39 Do you provide the student with an on-site orientation to your clinical site? (mark X) a) What does the orientation include? (mark (X) all that apply) Documentation/billing X Required assignments (eg, case study, diary/log, inservice) Learning style inventory optional X Review of goals/objectives of clinical experience Patient information/assignments X Student expectations Policies and procedures Supplemental readings: if in a specialty area Quality assurance X Tour of facility/department Reimbursement issues Other (specify below) In appreciation Many thanks for your time and cooperation in completing the CSIF and continuing to serve the physical therapy profession as clinical teachers and role models Your contributions to students’ professional growth and development ensure that patients today and tomorrow receive high-quality patient care services Index Saving the Completed Form…………………………………………………………………………………………… Page 29 Affiliated PT and PTA Educational Programs ………………………………………………………………….Page Arranging the Experience ……………………………………………………………………………………Page 15 Required Background …………………………………………………………………………… … Page 16 Required Medical Tests …………………………………………………………………………………Page 15 Available Learning Experiences …………………………………………………………………… …………… Diagnosis ……………………………………………………………………………………………… Page Health Professionals on Site ……………………………………………………………………… …….Page Specialty Clinics ……………………………………………………………………………………… Page Special Programs/Activities/Learning Opportunities ……………………………………………………….Page Center Coordinators of Clinical Education (CCCEs) ……………………………………………………………… Education…………………………………………………………………………………………… ….Page Employment Summary …………………………………………………………… ………………… Page Information…………………………………………………………………………………………… Page Teaching Preparation ………………………………………………………………………………… Page 10 Clinical Instructors ………………………………………………………………………………………………… Information…………………………………………………………………………………………Page 11- 12 Selection Criteria ……………………………………………………………………………………… Page Training…………………………………………………………………………………………………Page Clinical Site Accreditation………………………………………………………………………………… Page Clinical Site Ownership…………………………………………………………………………………… Page Clinical Site Primary Classification………………………………………………………………………… Page Information about the Clinical Site …………………………………………………………………………… Page Information about Physical Therapy Service at Primary Center ……………………………………………………………………………………Page Satellite Site Information ………………………………………………………………………………… Page Physical Therapy Service………………………………………………………………………………………… Hours …………………………………………………………………………………………………… Page Number of Patients ………………………………….………………………………………………… Page 30 Staffing………………………………………………………………………………………………… Page Student Information……………………………………………………………………………………………… Housing……………………………………………………………………………………………… Page 16 Meals………………………………………………………………………………………………….Page 17 Other ………………………………………………………………………………………………… Page 17 Stipends ……………………………………………………………………………………………… Page 17 Transportation … …………………………………………………………………………………….Page 17 31 ... Physician assistants X Enterostomal Therapist Podiatrists Exercise physiologists Prosthetists /Orthotists Psychologists X Respiratory therapists X Therapeutic recreation therapists Social workers... Hospital, Portland, OR Worcester City Hospital, Worcester, MA Staff Physical Therapist CCCE On-call Physical Therapist Staff Physical Therapist On-call Staff Physical therapist CCCE On-call Staff... from college; start with most current): EMPLOYER POSITION PERIOD OF EMPLOYMENT FROM Providence St Vincent Medical Center, Portland, OR Emanuel Childrens’ Hospital, Portland, OR Portland Public